1356471908 NPI number — MS. VALERIE F JACKSON LMSW, ACSW

Table of content: PADMAJA KROTHAPALLI (NPI 1174768931)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356471908 NPI number — MS. VALERIE F JACKSON LMSW, ACSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
VALERIE
Provider Middle Name:
F
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LMSW, ACSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356471908
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5418 BRIGHT CREEK CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLINT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48532-2254
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-845-6465
Provider Business Mailing Address Fax Number:
810-733-7317

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
G3163 FLUSHING RD
Provider Second Line Business Practice Location Address:
SUITE 214
Provider Business Practice Location Address City Name:
FLINT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48504-4365
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-845-6465
Provider Business Practice Location Address Fax Number:
810-733-7317
Provider Enumeration Date:
03/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  6801077180 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8008976850 . This is a "BC BS PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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